1. Drug Distribution systems in Hospitals
Dispensing to In – patients & Outpatients
Unit dose dispensing
Prepackaging
Dispensing of controlled substances

2. Drug Distribution systems or Dispensing to In-Patients
There are four systems in general use for dispensing drugs for inpatients.
They may be classified as follows:
(i) Individual Prescription Order System.
(ii) Complete Floor Stock System.
(iii) Combination of (i) and (ii).
(iv) The unit dose method.

3. 1.Individual prescription order system
This system is generally used by the small and/or private hospital because of the;
Reduced manpower requirement and
The desirability for individualized service.
Advantages of this system:
(i) All medication orders are directly reviewed by the pharmacist.
(ii) Provides for the interaction of pharmacist, doctor, nurse and patient.
(iii) Provides closer control of inventory.

4. 2. Complete floor stock system
In this drug distribution system medications are classified under two separate headings; charge floor stock drugs” and “noncharge floor stock drugs”.
Drugs on the nursing station are divided into “charge floor stock drugs” and “noncharge floor stock drugs”.
Charge floor stock drugs may be defined as those medications that are stocked/placed on the nursing station.
Under this system the nursing station carries both charge and non charge patient medication.
According to this condition the nurses store the drug and administer them to the patient according to the physician’s order.
It is the responsibility of the hospital pharmacist, working in cooperation with the nursing service, to develop ways & means where by adequate supplies of each are always on hand and, in appropriate situation that proper charges are made to the patients account.

5. Only the commonly used drugs are taken in this system.
The drugs which are Rarely used or particularly expensive drugs are omitted from floor stock but are dispensed upon the receipt of a prescription or medication order for the individual patient.
Although this system is used most often in governmental and other hospitals in which charges are not made to the patient, it does have applicability to the general hospital.
In some hospitals the complete floor stock system is successfully operated as a decentralized pharmacy under the direct supervision of a pharmacist.

6. Advantages of complete floor stock system:
(i) Ready availability of the required drugs.
(ii) Reduction in the number of drug order transcriptions for the pharmacy.
(iii) Reduction in the number of pharmacy personnel required.
Disadvantages of complete floor stock system:
(i) Medication errors may increase because the review of medication orders is eliminated.
(ii) Greater opportunity for pilferage (Theft of content).
(iii) Increased hazards associated with drug deterioration.
(iv) Lack of proper storage facilities on the ward.

7. 3. Combination of Individual prescription order system and complete floor stock system
Falling into this category are those hospitals which use;
The individual prescription or medication order system as their primary means of dispensing, but also
utilize a limited floor stock.
This combination system is probably the most commonly used in hospitals today and is modified to include the use of unit dose medications.

8. 4. Unit dose system Unit-dose medications have been defined as:
“Those medications which are ordered, packaged, handled, administered and charged in multiples of single dose units containing a predetermined amount of drugs or supply sufficient for one regular dose application or use.”

9. Advantages of unit dose system
(1) Patients receive improved pharmaceutical service 24 hours a day and are charged for only those doses, which are administered to them. (2) All doses of medication required at the nursing station are prepared by the pharmacy thus allowing the nurse more time for direct patient care. (3) Allow the pharmacists to interpret or check a copy of the physician’s original order thus reducing medication errors. (4) Elimination excessive duplication of orders and paper work at the nursing station and pharmacy. (5) Transfers intravenous preparation procedures to the pharmacy.

10. (6) Promotes more efficient utilization of professional and nonprofessional personnel. (7) Conserves space in nursing units by eliminating bulky floor stock. (8) Eliminates pilferage and drug waste. (9) Extends pharmacy coverage and control throughout the hospital from the time the physician writes the order to the time the patient receives the unit-dose. (10) Communication of medication orders and delivery systems are improved. (11) The pharmacists can get out of the pharmacy and onto the wards where they can perform their intended function as drug consultants and help provide the team effort that is needed for better patient care.

11. Unit dose dispensing procedure
Centralized unit-dose dispending:
The characteristic features of centralized unit-dose dispending are that all in-patient drugs are dispensed in unit-doses and all the drugs are stored in a central area pharmacy and dispensed at the time the dose is due to be given to the patient.
To operate the system effectively, electronic data processing equipment is not required, however delivery, systems such as medication carts are needed to get the unit-doses to the patients; also suction tube system (called pneumatic tube) or other means are required to send a copy of the physician’s original medication order to the pharmacy for direct interpretation by the pharmacist.

12. Decentralized unit-dose system
The decentralized unit-dose system, unlike the centralized system, operates through small satellite pharmacies located on each floor of the hospital.
The main pharmacy in this system becomes a procurement, storage, manufacturing and packaging center serving all the satellites.
The delivery system is accomplished by the use of medication carts.
This type of system can be used for a hospital with separate buildings or old delivery systems

13. Step-by step outline of the procedure entailed in a decentralized unit-dose system
1-Upon admission to the hospital, the patient is entered into the system. Diagnosis, allergies and other pertinent data are entered on to the Patient Profile card. 2-Direct copies of medication orders are sent to the pharmacist. 3-The medications ordered are entered on to the Patient Profile card. 4-Pharmacist checks medication order for allergies, drug –interactions, drug-laboratory test effects and rationale of therapy. 5- Dosage scheduled is coordinated with the nursing station. 6- Pharmacy technician picks medication orders. Placing drugs in bins of a- Transfer cart per dosage.

14. 7- Medication cart is filled for particular dosage schedule delivery 8-Pharmacist checks cart prior to release. 9-The nurse administers the medication and makes appropriate entry on her medication record. 10-Upon returns to the pharmacy, the cart is rechecked. 11-Throughout the entire sequence, the pharmacist is available for consultation by the doctors and nurses. In addition he is maintaining surveillance for discontinued orders

15. DRUG DISTRIBUTION AND CONTROL (UNIT DOSE SECTION)
Medication distribution is the responsibility of the pharmacy. The pharmacist, with the assistance of the pharmacy and therapeutics committee and the department of nursing, must develop policies and procedures that provides the safe distribution of all medications and related supplies to inpatients and outpatients.
For reasons of safety and economy, the preferred method to distribute drugs in institutions is the unit dose system.

16. Elements of unit dose distribution
Medications are contained in, and administered from, single unit or unit-dose packages
Medications are dispensed in ready-to-administer form.
For most medications, not more than a 24-hour supply of doses is provided to or available at the patient care area at any time
A patient medication profile is concurrently maintained in the pharmacy for each patient.
Floor stocks of drugs are minimized and limited to drugs for emergency use and routinely used “safe” items such mouthwash and antiseptic solutions.

17. Procedure
Writing the Order
Medication Order Sheets
Special Orders:
1. Writing the Order:
Medications should be given only on the written order of a qualified physician or other authorized prescriber.
Allowable exceptions to this rule (i.e., telephoned or verbal orders) should be put in written form immediately and the prescriber should countersign the nurse’s or pharmacist’s signed record of these orders within 48 (preferably 24) hours.
Only a pharmacist or registered nurse should accept such orders.
Provision should be made to place physician’s order in the patient’s chart, and a method for sending this information to the pharmacy should be developed.
Prescribers should specify the date and time medication orders are written.

18. Medication orders should be written legibly in ink and should include:
Patient’s name and location
Name (Generic) of medication.
Dosage expressed in the metric system, (i.e., units)
Frequency of administration.
Route of administration.
Signature of the physician.
Date and hour the order was written.
Any abbreviations used in medication orders should be agreed to and jointly adopted by the medical, nursing, pharmacy, and medical records staff of the institution. Any questions arising from a medication order, should be refer to the ordering physician.
It is desirable for the pharmacist to make (appropriate) entries in the patient’s medical chart pertinent to the patient’s drug therapy. Also, a duplicate record of the entry can be maintained in the pharmacy profile.
In computerized patient data systems, each prescriber should be assigned a unique identifier; this number should be included in all medication orders. Unauthorized personnel should not be able to gain assess to the system.

19. 2. Medication Order Sheets
The pharmacist (except in emergency situations) must receive the physician’s original order or a direct copy of the order before the drug is dispensed.
This permits the pharmacist to resolve questions or problems with drug order before the drug is dispensed and administered.
It also eliminates errors, which may arise when drug orders are transcribed onto another form for use by the pharmacy.

20. Several methods by which the pharmacy may receive physician’s original orders or direct copies are:
A. Self-copying order forms:
The physician’s order form is designed to make a direct copy (carbon or NCR), which is sent to the pharmacy. This method provides the pharmacist with a duplicate copy of the order and does not require special equipment.
There are two basic formats:
a. Orders for medications included among treatment orders. Use of this form allows the physician to continue writing his orders on the chart as he has been accustomed in the past, leaving all other details to hospital personnel.
b. Medication orders separated from other treatment orders on the order form. The separation of drug orders makes it easier for the pharmacist to review the order sheet.

21. B. Electromechanical:
Copying machines or similar devices may be used to produce and exact copy of the physician’s order.
Provision should be made to transmit physician’s orders to the pharmacy in the event of mechanical failure.
C. Computerized:
Computer systems in which the physician enters orders into a computer, which then stores and prints out the order in the pharmacy.
Any such system should provide for the pharmacist’s verification of any drug orders entered into the system by anyone other than an authorized prescriber.

22. 3. Special Orders:
Special Orders (ie emergency orders, and those for nonformulary drugs, investigational drugs, restricted-use drugs or controlled substances) should be processed according to specific written procedures meeting all applicable regulations and requirements.

23. DISPENSING OF CONTROLED SUBSTANCES
Addict: Any individual who habitually uses any narcotic drug so as to endanger the public morals, health, safety or welfare, or who is so far addicted to the use of narcotic drugs as to have lost the power or self control with reference to his addiction. Administer: The direct application of a controlled substances to the body of a patient or research subject by a practitioner or his agent or by the patient or research subject at the direction and in the presence of the practitioner. Controlled Substances: A drug or other substance, or immediate precursor, included in schedule I, II, III, IV or V of Part B of this title. The term dose not includes distilled spirits, wine, malt beverages or tobacco.

24. Depressant Or Stimulant Substance:
[A] A drug which contain any quantity of ;
barbituric acid or any of the salts of barbituric acid; or
(2) any derivative of barbituric acid ;or
[B] A drug which contains any quantity of ;
amphetamine or any of its optical isomers;
(2) any salt of amphetamine or any salt of an optical isomer of amphetamine; or
(3) any substance which the Attorney General, after investigation, has found to be, and by regulation designated as habit-forming because of its stimulant effect on the central nervous system; or
[C] Lysergic acid diethylamide; or
[D] Any drug which contains any quantity of a substance which the Attorney General, after investigation, has found to have, and by regulation designated as having, a potential for abuse because of its depressant or stimulant effect on the central nervous system or its hallucinogenic effect.

25. Narcotic Drug: means any of the following, whether produced directly or indirectly by extraction from substances of vegetable origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis.
[A] Opium, coca leaves and opiates.
[B] A compound, manufacture, salt, derivative, or preparation of opium, coca leaves or opiates.
[C] A substance (any compound, manufacture, salt, derivative, or preparation thereof) which is chemically identical with any substance referred to in [A] or [B] above.
Excluded are decocainized coca leaves or extracts of coca leaves, which do not contain cocaine or ecgonine.

26. SCHEDULES FOR CONTROLLED SUBSTANCES
(1) SCHEDULE I [A] The drug or other substance has a high potential for abuse. [B] The drug or other substance has no currently accepted medical use in treatment in the (United States). [C] There is a lack of accepted safety for use of the drug or other substance under medical supervision. (2) SCHEDULE II [B] The drug or other substance has recurrently accepted medical use in treatment in the (United States) or a currently accepted medical use with severe restrictions. [C] Abuse of the drug or other substances may lead to severe psychological or physical dependence.

27. (3) SCHEDULE III [A] The drug or other substance has a potential for abuse less than the drug or other substances in schedules I and II. [B] The drug or other substance has a currently accepted medical use in treatment in the (United States). [C] Abuse of the drug or other substances may lead to moderate or low physical dependence or high psychological dependence. (4) SCHEDULE IV [A] The drug or other substance has a low potential for abuse relative to the drug or other substances in schedules III. [C] Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule III.

28. (5) SCHEDULE V [A] The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedules IV. [B] The drug or other substance has a currently accepted medical use in treatment in the (United States). [C] Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV.

29. PRESCRIPTIONS
In dispensing of controlled substances, the following requirements should be considered with prescriptions:
Drugs may be dispensed on the oral prescription in an emergency situation.
Controlled substances in Schedule III or IV may not be dispensed without a written or oral prescription in conformity.
Such prescriptions may not be filled or refilled more than 6 months after the date thereof or be refilled more than 5 times after the date of the prescription unless renewed by the practitioner.
No controlled substance in Schedule V that is a drug may be distributed or dispensed other than for a medical purpose.
Prescriptions filled with controlled substances in Schedule II may be written in ink and must be signed by the practitioner issuing them. Prescriptions for narcotic substances in Schedules III, IV and V, must be kept in a separate file.

30. Registration of doctors who can prescribe Controlled Drugs
Doctors (Practitioners), in order to prescribe narcotics for or order administered (dispensed) to their patients in the hospital, must be licensed to practice under the laws of the (state) and must be duly registered with the DEA (Drug Enforcement Administration).
INTERNS and RESIDENTS: Registration requirements were waived to allow interns and residents to dispense and prescribe controlled substances under the registration of the hospital by which they are employed.

31. Responsibility for controlled substances
The administrative head of the hospital is responsible for the proper safeguarding and the handling of controlled substances within the hospital.
Responsibility for the purchase, storage, accountability and proper dispensing of bulk controlled substances within the hospital is delegated to the Pharmacist-in-Chief.
The Head Nurse of a nursing unit is responsible for the proper storage and use of the nursing unit’s controlled substances.

32. Preparation of orders
All controlled substances orders and records must be typed or written in ink or indelible pencil and signed in ink or indelible pencil.
Telephone orders
A doctor may order a controlled drug by telephone in case of necessity.
The nurse will write the order on the doctor's order sheet, stating that it is a telephone order and will sign the doctor's name and her own initials.
The controlled drug may then be administered at once.
The order must then be signed by the doctor with either his signature or his initials within 24 hours.
Verbal orders
A verbal order may be given by a doctor in an extreme emergency where time does not permit writing the order.
The nurse must write the order on the doctor’s order sheet.
The doctor must sign the order with either his signature or his initials within 24 hours.

33. Information on daily controlled drug administration sheet
The full information required on the Daily Controlled Drugs Administration Sheet is as follows:
1. Date.
2. Amount given.
3. Patient’s full name
4. Patient’s hospital number.
5. Name of doctor ordering.
6. Signature of nurse administering.
The following information is requested for auditing purposes and is not required by Federal law:
1. Number of tablets or ml administered
2. Filing out inventory column (to be retained for Pharmacy).

34. Prescribing controlled drug in out patient department
Prescriptions for Schedule II and other controlled substances drugs may be dispensed from Pharmacy and must include the following information.
a. Patient s full name
b. Patient’s address or hospital number
c. Date
d. Name and strength of drug prescribed.
e. Quantity of drug to be dispensed
f. DEA number and signature of physician
g. Frequency and route of administration

35. PREPACKAGING Many retail pharmacies purchase various over-the-counter
tablets and syrups in bulk quantities and prepackage the material in smaller-sized containers.
In the hospital pharmacy, the concept of prepackaging is utilized in both the large and the small hospital for it is, oftentimes, the means of coping with the periods of peak demand for pharmaceutical service.
In the small hospital, the pharmacist may prepackage only those items which he considers require too much time.
In some hospital pharmacies, items, which fall into this category, are narcotics, barbiturates, oily products, heavy syrups etc.

36. Adavantage:
Most large hospitals have found it economical to prepackage all ward stock items as well as the often-prescribed tablets; capsules, syrups, ointments and creams used both by the in-patients as well as the outpatient clinics.
Disadavantage
In large hospital pharmacy operation, it often requires a separate work force, special equipment, and detailed control procedures to ensure against the possibility of errors.

37. Factors considered in Prepackaging
a. Demand for the product.
Is it a year 'round demand or is it a seasonal demand?
Can this product be purchased in quantities to meet the demand,
yet have it packaged in small units by the manufacturer at a price
lower than the hospital cost to prepackage the same item in a
similar container?
b. What size units should be packaged? How many of each size?
c. What type of containers and closures must be used in order to
maintain therapeutic integrity?

38. d. What special labeling will be required. e
d. What special labeling will be required? e. Can the item be machine packaged or must hand counting be resorted to? f. What is the stability of the product? Is it dated? g. What will the unit cost of prepackaging amount to? Who should pay it?